Adverse Drug Events (ADEs) are defined as any harm to a patient
resulting from the use of a medication – whether the harms stem from medication
errors, overdoses, or adverse drug reactions or interactions. ADEs negatively
impact patient health in many ways and potentially cause unnecessary
hospitalization or death. Yet despite the serious nature of ADEs, the good news
is that most are preventable.

With this in mind, Telligen – the Quality Innovation Network-Quality
Improvement Organization (QIN-QIO) serving Colorado, Illinois and Iowa –
initiated a medication reconciliation project for members of its medication
safety care collaborative in response to their feedback, which indicated that
“medication reconciliation and communicating about patients’ medication lists”
are some of their biggest challenges involving medication safety for their
patients.

Medication reconciliation is a review of all the medications a patient
takes, including doses and frequency of use. “Medication reconciliation should
happen at every juncture in the [care] continuum,” says Katy Brown, Program Manager Lead and Clinical Pharmacy
Specialist at Telligen. “Not just once, not just twice, but every time the patient interacts with a
provider. Every time a med is changed, and every change in level of care
demands an accurate list,” says Brown. Doing so significantly reduces the risk
of ADEs and unnecessary hospitalizations, she says.

Telligen’s three-part project aimed to reduce ADEs by increasing the
frequency of medication reconciliation in a variety of care settings, including
hospitals, clinics and community pharmacies. The first part of the project
involved gathering general medication reconciliation process data from care
facilities. Telligen created a short online assessment that evaluated care facilities'
current medication reconciliation process against best practices. The QIN-QIO
then analyzed the collected data and assigned points to each step of the facility's medication reconciliation process to create an overall score.
Using this data, a Telligen pharmacist gave feedback to providers to help them
improve their processes.

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“Medication reconciliation should happen at every juncture in the [care] continuum. Not just once, not just twice, but every time the patient interacts with a provider.

One important recommendation was granting community pharmacists access
to discharge medication lists, as these health care providers typically have
extensive contact with patients post-discharge. Initially care providers were
reluctant to share their medication lists. Providers cited patient
confidentiality and legal concerns, time constraints, problems with faxing and
more. However, Telligen provided reassurance that medication lists were shared
with virtually all other stakeholders in the care continuum, including home
health agencies, nursing homes, primary care providers and specialists, among
others. In the end, the providers who chose to participate in Telligen’s
project saw immediate benefits in communication between patients and
caregivers, as well as lower rates of ADEs through this more holistic care
approach.

The project was developed and tested during the summer of 2015, implemented
in the fall of 2015 and completed in June of 2016. At completion, 15
communities in Iowa and Colorado had used the assessment tool, and
approximately 1,350 patient records
had been analyzed. Each “community” is a care collaborative comprised of health care providers and social service agencies. Thus far,
the project has helped prevent more than 440 potential ADEs.